NPE Process Guide for Hospitals

National Patient Experience Survey

Process Guide for Hospitals NPE Survey Process Guide for Hospitals

National Patient Experience Survey

Process Guide

Reference No: 001_PG

Revision No: 04

Author: National Patient Experience Survey team

Approved by: Rachel Flynn, Director of Health Information and Standards

Effective from: May 2019

Review date: May 2021 NPE Survey Process Guide for Hospitals

National Patient Experience Survey contact details

For queries regarding the hospital sub-processes, please contact:

Contact: Yvonne Cantwell (ICT Senior Projects Manager, HSE) Email: [email protected] Phone: 087 2431237

Contact: June Boulger, HSE Lead, National Patient Experience Survey Programme

Email: [email protected]

Phone: 086 8069829 NPE Survey Process Guide for Hospitals

Table of contents

1. Introduction ...... 5 1.1 What is the National Patient Experience Survey?...... 5 1.2 How does the survey work? ...... 5 1.3 What role do hospitals play in implementing the NPE Survey? ...... 5

2. NPE Contact Dataset ...... 6 2.1 NPE Eligibility Criteria ...... 6 2.2 What information should the NPE Contact Dataset contain? ...... 7

3. Identification, inclusion and uploading of eligible participants’ data .... 8 3.1 What role do hospitals play? ...... 8 3.2 NPE Hospital Names and Codes ...... 11 3.3 Security arrangements ...... 12

4. Opt out process ...... 14 4.1 What role do hospitals play in the opt out process? ...... 14 4.2 Opting out following discharge ...... 14

5. A Review of Death Notifications ...... 15

6. Review of data quality ...... 19 6.1 Duplicates ...... 22 6.2 Template for Quality Assurance Checks before sending the file ...... 22 NPE Survey Process Guide for Hospitals 1. Introduction

1.1 What is the National Patient Experience Survey?

The National Patient Experience (NPE) Survey is conducted on an annual basis. The purpose of the survey is to learn from patients’ feedback in order to improve hospital care. The National Patient Experience Survey falls under the National Care Experience Programme which is a partnership approach between the Health Information and Quality Authority (HIQA), the (HSE) and the Department of Health.

1.2 How does the survey work?

Eligible participants will receive a survey pack two weeks after discharge. This is followed by a reminder letter four weeks after discharge and a further and final survey pack six weeks after discharge. Participants can complete the survey online or by returning the survey in the post.

The core National Patient Experience (NPE) team is based in HIQA. HIQA has contracted a market research company B&A (Behaviour and Attitudes), to manage the collation of eligible participants’ contact data and distribution of surveys. HIQA is responsible for managing this service.

1.3 What role do hospitals play in implementing the NPE Survey?

Between 1 and 31 May, hospitals will be responsible for:

. identifying and entering eligible participants in the NPE Contact Dataset

. quality assuring data contained in the NPE Contact Dataset

. uploading the NPE Contact Datasets to B&A on a weekly basis

. opting patients out of the survey in hospital, if requested to do so.

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2. NPE Contact Dataset

The NPE Contact Dataset will consist of patients who are eligible to participate in the survey. Each hospital will identify eligible patients through the Patient Administration System (PAS).

2.1 NPE Eligibility Criteria

Eligible participants must:

- be discharged between 00:01 on 1 May and 23:59 on 31 May

- be aged 16 years or over

- have stayed 24 hours or more in a public acute hospital

- hold a postal address in the Republic of Ireland

The following should not be included in the NPE Contact Dataset – please double check your extraction codes to ensure they are not included:

- deceased patients

- persons under the age of 16 years at the time of sampling (patients born after 1st May 2003 should not be included)

- obstetrics/maternity service users (gynaecology patients are included in this survey

- psychiatry patients

- outpatients/day-case patients

- patients who stayed in hospital for less than 24 hours

- participants who reside in a prison institution

- patients who do not have a postal address in the Republic of Ireland

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2.2 What information should the NPE Contact Dataset contain? Name Format

First name e.g. Ciara

Family name e.g. Murphy

Address line 1 Current address

Address line 2 Current address

Address line 3 Current address, if applicable

Address line 4 Current address, if applicable

Address line 5 Current address, if applicable

Date of birth dd/mm/yyyy

Gender Female/Male

Date of admission dd/mm/yyyy

Source of admission category Emergency/non-emergency

Date of Discharge dd/mm/yyyy a) transfer to other hospital Discharge destination b) home/usual residence c) nursing home d) other

Length of stay XX days

Hospital group e.g. Dublin Midlands Hospital Group.

Hospital name For example,

NPE hospital code For example, NGH Table 1: NPE Contact Dataset - data fields and format

NB: All fields must contain the data items above in the format set out in the above table. Page 7 of 26 NPE Survey Process Guide for Hospitals 3. Identification, inclusion and uploading of eligible participants’ data

All NPE Contact Datasets should be uploaded to your sFTP (secure File Transfer Protocol) as per the schedule below in Table 2. If they are not received by 9am every Wednesday morning from 8 May to 5 June inclusive, they cannot be included in the survey run for that week. Yvonne Cantwell and her team will export the NPE Contact Datasets to B&A at 9am on Wednesday 8, 15, 22 and 29 May and 5 June.

Date of Task for hospitals Deadline for upload of extraction contact dataset Tuesday 7 May Extract for discharges 1–5 May Upload contact dataset by inclusive. 9am on 8 May Tuesday Extract for discharges 6–12 May Upload contact dataset by 14 May inclusive. 9am on 15 May Tuesday Extract for discharges 13–19 May Upload contact dataset by 21 May inclusive. 9am on 22 May Tuesday Extract for discharges 20–26 May Upload contact dataset by 28 May inclusive. 9am on 29 May Tuesday 4 June Extract for discharges 27–31 May Upload contact dataset by inclusive. 9am on 5 June Table 2: Schedule for extracting and submitting the NPE Contact Dataset

3.1 What role do hospitals play?

Step 1: apply eligibility criteria

. The designated person within each hospital will identify eligible participants by applying the following criteria. To be eligible, patients must:

- be discharged between 00:01 on 1 May and 23:59 on 31 May

- be aged 16 years or over

- have stayed 24 hours or more in a public acute hospital

- hold a postal address in the Republic of Ireland.

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. If the eligibility criteria are not adhered to, it will result in a data breach, which will be reported in line with the NPE’s Data Security Policy.

Step 2: create weekly NPE Contact Dataset

. Extract and upload eligible participants’ details to an Excel or CSV file, as per the fields in the NPE Contact Dataset outlined in Table 1 (page 7).

Step 3: quality assure the data

. Data quality checks are essential and are outlined in detail in Section 6. Review of Data Quality (page 19).

. Check all codes to ensure that only the details for eligible patients are extracted.

Step 4: save and title the NPE Contact Dataset

. The NPE Contact Dataset must be saved and titled appropriately. This step is crucial to ensure that each of your responses are attributed to your hospital. If the file code is not standardised, then the response will not appear under your hospital on the online dashboard.

. An NPE Survey code has been assigned to each hospital, which must be used in the filename. Hospital codes can be found in Table 3 (page 11/12).

. Files should be titled as follows: - your assigned hospital code_date of upload to B&A_QA e.g. Naas General Hospital: NGH_070519_QA

. Ensure you include QA (Quality Assurance) at the end of your filename. This confirms to B&A that your NPE Contact Dataset has been quality assured and is ready for download.

Step 5: upload NPE Contact Dataset to B&A

. Send the NPE Contact Dataset to B&A, using secure File Transfer Protocol (sFTP). The data will be securely stored by B&A for the duration of the NPE Survey cycle.

. Delete the dataset from the local computer and sFTP tunnel.

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Yvonne and her team will acknowledge receipt of the NPE Contact Dataset, and follow up where none have been received or if they have identified any quality issues.

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3.2 NPE Hospital Names and Codes

Saolta University Health Care Group

Hospital Name Hospital code Galway University Hospitals GUH Letterkenny University Hospital LUH MUHM Portiuncula University Hospital PUH Roscommon University Hospital RCH Sligo University Hospital SUH UL Hospitals

Hospital Name Hospital code Croom Orthopaedic Hospital ULCOH St John’s Hospital ULSJH ULHE ULHN University Hospital Limerick UHL Ireland East Hospital Group Hospital Name Hospital code Cappagh National Orthopaedic Hospital COH Mater Misericordiae University Hospital MMUH Midland Regional Hospital Mullingar MRHM Our Lady’s Hospital, Navan OLH Royal Victoria Eye and Ear Hospital RVEEH St Columcille’s Hospital SCH St Luke’s General Hospital SLGH St Michael’s Hospital SMH St Vincent’s University Hospital SVUH WGH Dublin Midlands Hospital Group Hospital Name Hospital Code Midland Regional Hospital Portlaoise MRHP Midland Regional Hospital Tullamore MHRT Naas General Hospital NGH St James’s Hospital SJH Tallaght University Hospital THD

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RCSI Hospital Group Hospital Name Hospital Code Beaumont Hospital BHD Cavan and Monaghan Hospital CMH CHB LCH Our Lady of Lourdes Hospital OLOL South/South West Hospital Group Hospital Name Hospital Code University Hospital Waterford UHW BGH CUH Kilcreene Regional Orthopaedic Hospital KOH MGH Mercy University Hospital MUHC South Infirmary Victoria University Hospital SIVUH South Tipperary General Hospital STGH University Hospital Kerry UHK Table 3: NPE hospital names and codes

3.3 Security arrangements

The NPE Survey complies with data protection laws including the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. Eligible participants’ information will be used for the sole purpose of the survey and will be deleted as soon as the survey is complete. Further details can be found on www.patientexperience.ie.

Each hospital is responsible for ensuring that their NPE Contact Dataset is secure, and must adhere to HSE security policies at individual hospital level.

At all times there must be clarity and defined ownership around:

1. what PC the NPE Contact Dataset is stored on

2. what security measures are in place to ensure that only the nominated person(s) has access to the NPE Contact Dataset

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3. NCEP retention and destruction policies and processes are adhered to. For more information, please see https://www.patientexperience.ie/about-the- survey/information-governance/

4. all NPE Contact Datasets are deleted from your PC on 19 July 2019.

Identification of Eligible Participants

Hospital applies eligibility criteria

If a participant is not eligible If a participant is eligible

Extract participant details from PAS, as per the NPE Contact Dataset requirements No further action is needed

Upload those contact details to the NPE Contact Dataset

Hospital Conduct Data Quality Checks - please refer to data quality process on page 19

Save and title the NPE Contact Dataset appropriately

Upload the NPE Contact Dataset Hospital

Figure 1: Identification of eligible participants

Page 13 of 26 NPE Survey Process Guide for Hospitals 4. Opt out process

Participation in the NPE Survey is voluntary. If a participant does not wish to take part in the survey, there are processes in place to facilitate opt outs.

4.1 What role do hospitals play in the opt out process?

Upon receipt of their NPE Survey discharge pack, patients can request to opt out. The hospital must take the following steps:

1. The hospital staff member will record the patient’s name, address and date of birth on the envelope of their survey discharge pack and send it to the PAS office, via internal post.

2. The PAS office will remove the patient’s name from the NPE Contact Dataset prior to uploading it to B&A. This will ensure that the patient does not receive any correspondence about the survey.

3. The patient’s envelope, containing the patient’s details, should then be shredded immediately.

4.2 Opting out following discharge

Eligible participants can also opt out by

- calling the NPE Freephone number: 1800 314 093

- logging on to www.patientexperience.ie

emailing [email protected]

- returning the freepost survey pack in the post

- not responding to the survey.

Requests to opt out will be processed and logged in the NPE Opt Out File. The participant’s details will be destroyed at the end of the respective survey cycle.

Page 14 of 26 NPE Survey Process Guide for Hospitals 5. A Review of Death Notifications

The NPE Survey involves the input of participants’ details following their discharge from hospital. There is a risk that some participants may pass away over the course of the survey period. As part of the quality assurance process, it is essential that adequate and standardised measures are taken to prevent the distribution of survey packs to deceased participants, wherever possible. A nominated staff member within each hospital will be responsible for this process.

This process will be conducted for 42 days (six weeks) following the survey period to ensure that participants discharged in the latter half of the month are accounted for.

Each participating hospital is responsible for the following steps:

Step 1: review available resources as per the schedule shown in Table 4 on the next page.

Step 2: verify deceased participants’ details, against the NPE Contact Dataset.

Step 3: upload the names to the Death Check Dataset, as per the data fields outlined in Table 5 on the next page.

Step 4: save the dataset and apply the correct filename. Filename format: DC_your assigned hospital code_date of upload e.g. Naas General Hospital: DC_NGH_070519

Step 5: upload Death Check Dataset to B&A as per agreed timelines in Table 4.

Step 6: delete the dataset from the local computer and sFTP tunnel.

The HSE will acknowledge receipt of the Death Checks, and follow up where none have been received.

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Date Review of death notifications

Tuesday 7 May Review of death notifications for discharges from 1–5 May inclusive.

Tuesday 14 May Review of death notifications for discharges from 1–12 May inclusive.

Tuesday 21 May Review of death notifications for discharges from 1–19 May inclusive.

Tuesday 28 May Review of death notifications for discharges from 1–26 May inclusive.

Tuesday 4 June Review of death notifications for discharges from 1–31 May inclusive.

Tuesday 11 June Review of death notifications for discharges from 1–31 May inclusive.

Tuesday 18 June Review of death notifications for discharges from 7–31 May inclusive.

Tuesday 25 June Review of death notifications for discharges from 14–31 May inclusive.

Tuesday 2 July Death checks for discharges from 21–31 May inclusive.

Tuesday 9 July Death checks for discharges from 28–31 May inclusive.

Table 4: Schedule for conducting and submitting Death Checks to B&A

Name Usage

First name e.g. Ciara

Family name e.g. Murphy Address line 1 Current address Address line 2 Current address Address line 3 Current address Address line 4 Current address, if applicable Address line 5 Current address, if applicable

Page 16 of 26 NPE Survey Process Guide for Hospitals Date of birth dd/mm/yyyy Date of death dd/mm/yyyy Source of death notification e.g. Nursing home, Relative, RIP.ie, G.P., Hospice, Other, Unknown Hospital name e.g. Naas General Hospital Table 5: Data fields for the NPE Death Check file

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Review of death notifications within each hospital

Designated person reviews national and local resources to identify any deceased participants

al

Hospit Upload the names of Save and title the Upload Death Delete the Cross-check with deceased participants Death Check Check Dataset dataset, upon the NPE Contact to the Death Check Dataset using to Managed confirmation of Dataset Dataset correct file name Service receipt

Figure 2: Death check process Table 6: Death checks rocess

Page 18 of 26 NPE Survey Process Guide for Hospitals 6. Review of data quality

The NPE Contact Dataset needs to be fully quality assured before being uploaded to B&A, to ensure that it is accurate and up to date. A designated staff member within the hospital will be assigned to the task of managing data quality for the NPE Survey on behalf of the hospital.

As part of the admission process, each hospital will be required to verify a patient’s current address as the success of the survey is dependent on an accurate postal address. Please ensure that the relevant staff are aware of the importance of this step when recording patient details.

Table 6 below and Figure 3 on page 21 outline the data quality assurance process.

Data quality check Description

1. All required fields are captured and . All fields should be extracted from PAS complete. and recorded in the format as per Table 1: NPE Contact Dataset (page 7)

. Data should be provided under the correct fields, i.e. do not place data for 2. The accuracy of data fields has been ‘admission source’ in the ‘discharge verified. destination’ field. . Ensure that the format of dates are aligned correctly, i.e. dd/mm/yyyy.

Eligible patients must:

. be discharged between 1 and 31 May

3. The dataset only contains the details . be aged 16 years or over of eligible patients. . have stayed 24 hours or more in a public acute hospital

. hold a postal address in the Republic of Ireland.

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4. The dataset only contains eligible . Double check all codes so that no patients. non-eligible participants are included.

. Examples include commas, full stops, 5. The dataset is free of unnecessary etc., as these can interfere with the characters. recognition of your hospital by the software collating the response data.

. Please adhere to the hospital’s name, as outlined in Table 3 (page 11/12), at all times for each upload.

6. The hospital name and hospital group . Please do not use variations of the is consistent for each upload. hospital name when naming files as the software collating the response data will view different names as two separate hospitals.

. Participants who have died since their 7. A review of death notices has been time of discharge must be identified and conducted. uploaded to the death check dataset to ensure no further correspondence is issued.

. Ensure that each record contains accurate, complete and valid data as per 8. Audit every 10th record. the NPE Contact Dataset

. e.g. Naas General Hospital: 9. The file is saved appropriately with the NGH_070519_QA correct filename and hospital code.

Table 6: Review of data quality

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Review of Data Quality

Verify participant’s address upon admission

Check all relevant fields in the NPE Contact Dataset are captured

Ensure all relevant fields are complete

Verify accurate data fields under appropriate headings Hospitals

Audit every 10 records to ensure accuracy

Ensure all deceased participants are uploaded to the Death Check Dataset

Ensure extract file is named Hospital correctly

Figure 3: Review of Data Quality

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6.1 Duplicates Data quality checks should also include the identification and removal of duplicates. This means that if an eligible participant’s details appear twice in the same NPE Contact Dataset, the second set of the participant’s details should be removed. Care should be taken to ensure that all of the data fields are formatted as outlined in the NPE Contact Dataset, to avoid removing two different, eligible participants with similar or identical names.

6.2 Template for Quality Assurance Checks before sending the file

General Checks

. Ensure there are field headers in Row 1 of the file. . Ensure all the appropriate field headings are included and displayed exactly as shown below and in the order as shown below . Remove any additional columns that are not displayed below . Sort the file in alphabetical order and ensure you remove all duplicates . File Name should be displayed as e.g. COH_070519_QA.xls. Quality assurance must be on the end if there is no QA it will be assumed that this has not been Quality assurance and it will miss the run for that week. . Remove NULL from any fields.

Field Sample Text Checks

First Name Yvonne

Family Name Cantwell

Address Line 1 Dr Steevens . Ensure that there are only address details Hospital in the field no additional comments or remarks. . No commas, dashes or unnecessary characters.

Address Line 2 Steevens Lane . Ensure that there are only address details in the field no additional comments or remarks. . No commas, dashes or unnecessary characters.

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Address Line 3 Dublin 8 . Ensure that there are only address details in the field no additional comments or remarks. . No commas, dashes or unnecessary characters.

Address Line 4 . Ensure that there are only address details in the field no additional comments or remarks. . No Commas, dashes or unnecessary characters.

Address Line 5 Dublin . Ensure that there are only address details in the field no additional comments or remarks. . No commas, dashes or unnecessary characters.

Date of Birth 01/07/1980 . Format should be dd/mm/yyyy. . No quotation marks. . Ensure there is no time in the field hh:mm. . Ensure there are no spaces before the date of birth do this by aligning the column to the right.

Gender Female . Ensure the full word “Female” or “Male” is in each column. . There should not be an initial "F" or “M”.

Date Of 02/02/2018 . Format should be dd/mm/yyyy. Admission . No quotation marks. . Ensure there is no time in the field hh:mm. . Ensure there are no spaces before the date of birth do this by aligning the column to the right.

Source Of Emergency Dept . Ensure this is appropriate Source Data. Admission Category

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Date Of 05/05/2019 . Format should be dd/mm/yyyy. Discharge . No quotation marks. . Ensure there is no time in the field hh:mm. . Ensure there are no spaces before the date of birth do this by aligning the column to the right.

Discharge Home . Ensure this is the appropriate Discharge Destination Data.

Length of stay 92 . Ensure the minimum number is “1”, this should be in days and not hours. . Ensure that there are numbers ONLY, no text.

Hospital Group Ireland East . Ensure you have the spelling and format Hospital Group exactly as displayed in Table 3 (page 11/12).

Hospital Name St. Luke’s General . Ensure you have the spelling and format Hospital exactly as displayed in Table 3 (page 11/12).

NPE Hospital SLGH . Ensure you have the spelling and format Code exactly as displayed in Table 3 (page 11/12). Table 7: Template for quality assurance checks

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Revision

Number Effective date Reason for update

01 1 May 2017 Original document release

02 1 May 2018 Revised in line with changes in survey programme

03 8 May 2018 Revised based on consultation with stakeholders

04 1 May 2019 Revised in line with changes in survey programme

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